Lisbon Addictions 2017 Understanding Addiction: A Health Inequalities and Social Harms Perspective

1. Lisbon Addictions 2017 Understanding Addiction: A Health Inequalities and Social Harms Perspective Dr Aileen O’Gorman University of the West of Scotland Aileen.OGorman@uws.ac.uk

2. This paper draws on a series of qualitative and ethnographic neighbourhood studies and analyses of drug trends and public policies in the UK, Scotland and Ireland 2014

3. Estimated quarter of a billion people (5%) used drugs at least once in 2015 (UNODC:2017). Approximately one in ten (29.5m /0.6%) designated with a drug use disorder and require treatment. Who are the people whose drug use is problematised and why?

4. Global burden of disease and the concept of DALY (disability-adjusted life years) flawed focused on individual risk rather than the ecology of disease exclude local context of poverty as a modifier of disease impact and the burden of disease on the poor. (King & Bertino, 2008) strong links between poverty, deprivation, inequalities and problem drug use (SDF, 2007).

5. One way of unpicking this association is to focus on the socio-economic and political process that facilitate their disproportionate experience of drug-related harms among marginalised communities. My research looks beyond the drug and individual drug users’ behaviour to the risk environment - the ‘physical, social, economic & policy contexts’ Rhodes (2002) – they inhabit

7. Source: http://www.instituteofhealthequity.org/presentations/presentation-slides

8. Socio-economic deprivation Age standardised mortality rates (drug misuse deaths per 1 million population) by lower super output areas sorted into quintiles of the Index of Multiple Deprivation (1 is the most deprived), 2001-2014. Alex Stevens, University of Kent, 2017

9. Policy-related harms or ‘policy induced losses’: the negative outcomes for people resulting from decisions taken, or not, by national and local government and statutory agencies. A form of ‘structural violence’ by the state: ‘the avoidable impairment of fundamental human needs’. (Galtung) Intended or unintended consequences of policy or the outcomes of a politics of indifference?

10. What can ‘Health Inequalities’ teach us? ‘Inequalities in health arise because of inequalities in society – in the conditions in which people are born, grow, live, work and age’ (Marmot, 2010). an uneven distribution of risk factors … with the burden borne disproportionately by those in the lower socio-economic groups The causes of health inequality are complex but they do not arise by chance. The social determinants of health are largely the results of public policy.

11. Social and structural determinants of health (and health inequalities)

12. General acceptance that inequalities in health arise out of inequalities in society which arise, largely, from public policy (Marmot, 2010) Yet, little attention is paid to the role politics and policies play in shaping the macrosocial determinants of health and urban environments that produce and reproduce ill health and drug-related harms– the risk environment

13. Restructuring of the welfare state – cuts to education, housing, drug services, support services for marginalised comunities. Increased welfare conditionality - ‘non-compliance’ = cessation of benefit Change in disability supports – reassessment, regular reviews Removal/reduction of welfare benefits to young people. Neo-liberal politics of austerity

14. increasingly hostile drug policy environment dominant public and political discourses individualise social and drug problems framed as a ‘function of individual and cultural pathology’ and of ‘pharmacologically disordered citizens’. (Fraser & Moore, 2011) focus on deficit model (Monaghan & Wincup, 2013) requires individual behavioural change rather than policy deficits

15. In Scotland and Ireland (where my research is based) we find concentrated areas of intense deprivation where inequalities in health, employment, education and access to services persist. Individuals from deprived communities are more likely to experience morbidity and mortality from drug use. For example, in Scotland, in the most deprived quintile drug-related hospital admissions 14 times higher in the most deprived communities. Impact

16. Number of drug-related general acute hospital stays in Scotland in 2015/6 by deprivation quintile.

17. Scotland - highest Rate of Drug-Related Deaths in the EU ? Drug-related deaths (per 1m population) in selected countries, and the EU http://www.talkingdrugs.org/scotland-may-now-have-highest-rate-of-drug-related-deaths-in-the-eu

18. Scotland context of DRDs Parkinson et al. (2016) identified now aging cohort at risk from the most deprived areas and who came to age in 1990s exposed to the negative consequences of the changing social, economic and political contexts of the 1980s (Thatherism and neo-liberalism) recent exposure to a more ‘flexible’ labour market and greater conditionality and sanctions in the social security system increases the risk of DRDs

19. How do we move forward? Responding to ‘problem’ drug use requires responding to the drivers of risk environments and the social and structural determinants of drug-related harms. Consider the differential experience of drug-related harms with a focus on social justice and SDGs to address the disproportionate extent of drug-related harms experienced by those on the margins.